Researchers conclude that acupuncture increases the total effective rate of drug therapy for the treatment of rheumatoid arthritis. Researchers from the Second Affiliated Hospital of Anhui University of Traditional Chinese Medicine combined acupuncture with standard drug therapy. Patients receiving both drug therapy and acupuncture in a combined treatment protocol had superior patient outcomes compared with patients receiving only drug therapy. The researchers conclude that the addition of acupuncture to standard drug therapy is effective for the alleviation of relevant symptoms and the regulation of rheumatoid arthritis (RA) related laboratory indices (rheumatoid factor, hypersensitive C-reactive protein, erythrocyte sedimentation rate, platelet, fibrinogen, and D-dimer).  The study was approved and funded by the National Natural Science Foundation of China.
Before getting into the results, let’s first take a look at the biomarkers used in the study and their clinical significance. Rheumatoid factor (RF) is a protein found in RA patients. RF can attack healthy tissue in the body. C-reactive protein (CRP) is a protein produced by the liver in response to inflammation and is measured with an hs-CRP (high-sensitivity C-reactive protein) test.
The erythrocyte sedimentation rate (ESR) test reflects the degree of inflammation in the body. It measures how quickly red blood cells settle at the bottom of a test tube.  The faster the rate is above the normal range, the greater the chance of increased inflammation.
CRP and ESR play an important role in measuring RA disease severity.  Fibrinogen (FBG) is a glycoprotein found in the blood. D-dimer (DD) is a fibrin degradation product resulting from the degradation of blood clots by fibrinolysis. FBG and DD are essential diagnostic tools for RA because they reflect the activity of the fibrinolysis system and abnormalities of the fibrinolysis system play an important role in the pathogenesis of RA.  Platelet (PLT) count is another diagnostic tool reflecting disease activity and response to treatment for RA. 
The researchers (Zhu et al.) used the following study design. A total of 56 patients from the Anhui Provincial Acupuncture Hospital participated in the study. They were diagnosed with RA between January 2016 and March 2017. The following selection criteria were applied:
- Consistent with the RA diagnostic criteria established by the 2010 American College of Rheumatology (ACR)/European League Against Rheumatism (EULAR) 
- Ages between 18 to 80 years
- Informed consent was signed
- A disease activity score (DAS-28) of >2.6 according to the RA disease activity standard formulated by the EULAR 
The following exclusion criteria were applied:
- RA combined with connective tissue diseases
- RA with severe joint deformity
- RA with a DAS-28 score of ≤2.6
- Received biologic treatment (anti-TNF/IL-1 drugs) for the treatment of RA within 3 months
- Pregnant or lactating
- Severe and comorbid cardiovascular, cerebrovascular, hematopoietic, liver, kidney diseases
- Nervous and mental disorders
Participants were randomly divided into a treatment group and a control group, with 28 patients in each group. Both groups were equivalent in gender, age, and course of disease, setting the basis for a fair comparison of results. The treatment group had 7 males and 21 females, mean age 51, mean course of disease 11.3 ±7.6 years. The control group had 7 males and 21 females, mean age 53, mean course of disease 12.8 ±8.1 years.
For both groups, patients received identical drug therapy. Ten milligrams of methotrexate and 5 mg of folate were given once a week. Methotrexate is an immune system suppressant used for the treatment of rheumatoid arthritis and other autoimmune diseases. One downside is that the medication leads to folate deficiency. Folate supplementation is used to eliminate the adverse effects related to folate deficiency. In addition, 0.3g of ibuprofen was administered twice per day. Ibuprofen is a non-steroidal anti-inflammatory drug (NSAID) with anti-inflammatory and analgesic effects. All three drugs were consumed after meals. Every 30 days of tablet consumption consisted of one treatment course. A total of 3 courses were administered.
Only the treatment group received acupuncture. The following acupoints were administered:
- BL18 (Ganshu)
- BL20 (Pishu)
- BL23 (Shenshu)
- LI4 (Hegu)
- LI11 (Quchi)
- ST36 (Zusanli)
- Ashi points (local)
A 0.30 x 25 mm or 0.30 x 40 mm disposable acupuncture needle was inserted into each acupoint, reaching standard insertion depths. Upon arrival of a deqi sensation, the ping bu ping xie (tonify and sedate) manipulation technique was applied to each needle. Next, a needle retention time of 30 minutes was observed. The treatment was conducted once per day. The patients received six days of treatment plus a one day break every week. Every 30 days of acupuncture treatment consisted of one treatment course. A total of three courses were administered.
Multiple subjective and objective instruments were used to measure patient outcomes. First, serological indexes were evaluated, including RF, hs-CRP, ESR, PLT, FBG, and D-dimer. Second, the blood stasis score was measured using Clinical Guidelines for Traditional Chinese Medicine New Drugs as a reference.  RA falls into the Bi Zheng (impediment disease) category according to the traditional Chinese medicine, which refers to poor circulation of qi and blood stasis. The following parameters were used to evaluate the severity of blood stasis: joint tingling, lip color, tongue, pulse, subcutaneous ecchymosis, and encrustation of skin.
Third, the symptom grade quantitative score was measured using the Clinical Guidelines for Traditional Chinese Medicine New Drugs. Fourth, the 28-joint disease activity score (DAS-28) was calculated using the RA disease activity standard formulated by the EULAR. A DAS-28 score of >5.1 indicates high disease activity. A DAS-28 score of >3.2 and ≤5.1 indicates middle disease activity. A DAS-28 score of >2.6 and ≤3.2 indicates low disease activity. A DAS-28 score of ≤2.6 indicates remission. Fifth, the total effective rate was recorded.
The levels of RF, hs-CRP, ESR, PLT, D-dimer, and FBG were significantly improved in the two groups compared with levels before treatment. The hs-CRP and ESR levels, blood stasis scores, symptom grade quantitative scores, and DAS-28 scores in the acupuncture treatment group were significantly better compared with the control group. The total effective rate in the acupuncture treatment group was 85.7% (24/28), which was greater than 75.0% (21/28) in the drug monotherapy control group.
The addition of acupuncture into the drug therapy regimen of care increased the total effective rate by 10.7%. Application of acupoints Ganshu (BL18), Pishu (BL20), Shenshu (BL23), Hegu (LI4), Quchi (LI11), Zusanli (ST36), and local ashi points are the acupoints used in the investigation and are proven to produce subjective and objective results. Zhu et al. conclude that acupuncture is effective for the relief of rheumatoid arthritis and improves patient outcomes.
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